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Education campaign informs DIII decision on sickle cell trait legislation

By Gary Brown

Last January, many Division III delegates said they were unprepared to vote on a proposal to require sickle cell trait status confirmation status, which caused its referral from the Convention floor for further review without really much of a chance to even debate the proposal’s merits.

Since then, the Division III governance structure has done all it can to keep that from happening again at the 2013 Convention.

It’s not that the governance structure is trying to coerce an outcome, though the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, and the Division III Management and Presidents Councils are actively supporting the revised proposal. It’s more that the Councils and committees want to ensure that there’s an informed membership casting ballots at the Division III business session on Jan. 19 in Grapevine, Texas.

To address that sense of “under-preparedness,” Division III governance leaders have engaged in a comprehensive educational effort that accompanies a revised and more comprehensive legislative proposal in an effort to inform the membership.

“We’re much more educated to address the issue this year,” said Redlands Athletics Director and Management Council chair Jeff Martinez when asked what he thought was different now than 10 months ago. “People should now understand not only the reasons for the proposal and the benefits it provides for student-athlete health and safety but also how we go about implementing it.”

The new proposal (No. 4 in the Official Notice that will be available Nov. 15) would require confirmation of sickle cell trait status for all student-athletes no later than the 2014-15 academic year, including mandatory confirmation of status for all incoming student-athletes (first-year and transfers) in 2013-14.

Under the proposal, which would be effective Aug. 1, 2013, schools can confirm the sickle cell trait status of student-athletes before participation in intercollegiate athletics in one of the following manners:

  • Documentation: The student-athlete may provide documented results of a sickle cell solubility test administered before participation;
  • Pending documentation: A student-athlete who has taken a sickle cell solubility test but whose results are not yet confirmed may participate provided the student-athlete engages in mandatory education, signs a waiver and receives appropriate precautions as set forth by the institution; or
  • Opt-out: The student-athlete may sign a waiver declining confirmation of sickle cell trait status. Before signing a waiver, the student-athlete shall be provided education regarding the implications of exercising the waiver option. Before athletics participation, a student-athlete who signs a waiver under this provision shall engage in mandatory education regarding sickle cell trait status and receive accommodations as determined by the institution.

The original proposal at the 2012 Convention required confirmation status but wasn’t as comprehensive or as educationally grounded. The new version is a result of collaboration with the competitive-safeguards committee, the group to which the original proposal was referred. The new proposal has generated support at each step along the governance review path.

Most people think the new proposal is better than its predecessor.

“To our division’s credit, perhaps there was wisdom in our hesitancy,” said Washington and Lee Athletics Director Jan Hathorn, who also is a member of the Management Council. “To some, last year’s action may have looked like people were just being stubborn, but actually, the hesitancy was based more on not knowing what this was all about, or where it was coming from, than simple defiance. I was a doubter in January as well, but the investment in sending this back and looking into the issue in detail has been very informative for me.”

New and improved

So what has changed? Most obvious is the proposal itself. The educational component makes it unique. While Divisions I and II have already passed legislation to require confirmation of sickle cell trait status, the Division III proposal focuses on educating all student-athletes, even if they think they’re not at risk. While the overwhelming perception is that sickle cell trait is prevalent only in African-Americans, evidence suggests anyone could be a carrier.

The educational component also should diffuse the fear factor associated with confirmation of status. Being a sickle cell trait carrier isn’t a barrier to sports participation. On the contrary, once status is confirmed, coaches and athletic training staffs can properly manage the condition to the student-athlete’s benefit.

A case at Puget Sound is a good example. Football player Nassar Kyobe was experiencing symptoms but had no idea of his sickle cell trait status until head athletic trainer Craig Bennett asked him if he’d ever been tested. Once Kyobe’s status was confirmed, his situation could be properly managed.

“It doesn’t have to be a fear-based reaction,” said Bennett. “This doesn’t preclude somebody from the opportunities they would normally have. The intent is to educate schools about how to handle this situation. That same education helps the student-athlete understand what he or she has to do to participate safely, and it prepares coaches to help that student-athlete get the most out of his or her experience.”

Another positive twist on the legislation is the required education for those who opt out of confirming their status. While any proposal of this nature has to offer an opt-out for student-athletes who choose not to confirm sickle cell trait status, the Division III proposal requires schools to explain the risks for those who take the opt-out route. Those student-athletes also are given appropriate accommodations as determined by each institution’s athletic training staff. Advocates for the proposal believe that will benefit everyone and keep the opt-out numbers low.

Management Council member Lori Runksmeier, who serves as the Council’s liaison to the competitive-safeguards committee, said a lot of people who were concerned about the proposal last year assumed there would be a high number of opt outs if the legislation were to have been approved.

“Actually, as it is turning out, a ‘yes’ vote last year wouldn’t have done anything to change the opt-out option – it would have just made it more attractive,” said Runksmeier, the athletics director at New England College. “Now, even though we’ve had to delay implementation for a year, the educational component in the revised proposal better addresses the opt-out concern.”

Because Division I and II already have implemented confirmation of sickle cell trait status legislation, the NCAA research staff is reissuing an abbreviated 2011 survey to athletic trainers in all divisions this month to provide additional feedback about the use of written releases connected with confirmation of status to the Division III membership before the Convention.

Costs and logistics

In addition to confusion about the why’s and how’s of last year’s proposal, a lot of talk surfaced about what the legislation would cost.

There appears to be good news on that front. First, the NCAA has negotiated an arrangement with Quest Diagnostics, a national lab service, to provide testing and results in a timely fashion for a reduced rate. For as low as just $8.50 (up to $32.50 depending on the process), student-athletes can receive their results in a matter of days.

Second, the Management Council and Presidents Council at their October meetings approved a one-time $220,000 allocation to help defray the costs of sickle cell trait testing if the new proposal passes in January.

That’s about $500 per school, and while $500 won’t cover all of the costs associated with testing the entire freshman class for 2013-14 (which Proposal No. 4 requires), it represents a good-faith effort from the division to share the burden in order to ensure student-athlete health and safety.

Management Council chair Martinez said it reflects the input the governance structure has sought about the effects of this proposal within a 450-member division that has a huge variance in the ability to provide resources when legislation mandates that institutions do so.

“Our endorsement of the allocation indicates we have heard the concern and are willing to help out as a division,” Martinez said.

The $500 would in most cases cover the costs of about 30 to 50 student-athletes – about one-third of an average incoming class. Assuming another third already have confirmed their sickle cell trait status upon coming to campus, that leaves a smaller portion for the school to account for financially in cases where students are unable to pick up the costs themselves (institutions would not be required to pay for testing, though the new allocation could be an incentive for more schools to help out).

The logistics of implementation for the entire incoming class and a potentially tight turnaround for fall-sport athletes loomed as a barrier last year. But New England’s Runksmeier was among those who decided to try it out before casting a verdict.

“I asked my athletic trainers to give it a shot this fall,” she said. “We found that it wasn’t as scary or onerous as some might originally have thought. We didn’t require confirmation, but just with the recommendation, we got 75 percent of our first-year athletes to confirm their status.”

The same thing happened at Lewis and Clark College several years ago when it became clear that the NCAA was thinking about requiring confirmation status.

Mark Pietrok, senior assistant athletics director and head athletic trainer there, took the matter to his senior administration. They decided that if the NCAA was going to recommend sickle cell trait status confirmation, then so would the school. Pietrok said his staff asked student-athletes to start researching their sickle cell trait status, because in a year Lewis and Clark was going to start requiring confirmation of that status for athletics participation there.

“The hard part is the first year that you have to get everyone through it,” Pietrok said. “Our year of education really helped us. Not everyone paid attention to it until they had to, but I bet 25 percent of them did, which made our job the following year that much easier. It was not nearly as difficult as I anticipated.”

Bennett from Puget Sound agreed that the perceived burden on under-resourced schools and athletic training staffs was a legitimate concern, but that the benefits of knowing trumped not doing it at all.

“If you already have a health-screening procedure set up, and if you’re going to educate your student-athletes about medical issues – which most of us already do – then I don’t personally see the sickle cell trait status confirmation as a burden,” he said. “And why wouldn’t you want to know if your student-athletes have this condition so you can better manage it?” (Watch the case-study video.)

That knowledge paid off at Lewis and Clark. Due to the school’s requirement, Pietrok’s staff identified three student-athletes who carry the trait and didn’t know it (two African-Americans and one from Mediterranean descent). That has been the case at other schools that already require testing as well.

“For those student-athletes, we’ve been able to knock down the fear factor,” Pietrok said. “It’s not a scary thing to manage this situation, and we’ve done a real service for these student-athletes by providing them and their coaches with appropriate education.”

Hematology, institutional autonomy

Another concern that surfaced earlier this year was a statement from the American Society of Hematology (ASH) questioning the NCAA’s sickle cell trait status confirmation policy. In place of status confirmation, the ASH said it instead favors “universal preventative interventions that will render screening unnecessary,” offering as examples policies for heat acclimatization, work-rest cycles and guidelines for hydration implemented by the Army.

The competitive-safeguards committee noted that the NCAA and the ASH share some similar positions. As an example, the NCAA supports universal preventative interventions and has included such procedures in its own publications, legislation and best-practice measures. The committee also agrees that additional research and public education on the role of sickle cell trait in life and athletics is needed.

But the committee also reaffirmed its position that, for the student-athlete population, knowledge and education of sickle cell trait status is important for all student-athletes in relation to their safety, health and well-being. The reaffirmation maintained the position the committee first took with its recommendation to the membership in 2009 that sickle cell trait status be confirmed in all student-athletes in all divisions. The recommendation was added at that time to the NCAA’sSports Medicine Handbook.

Since the ASH statement was issued, the NCAA has worked with the group on a number of initiatives. Two collaborative meetings, one with the military and one with the American College of Sports Medicine, also have been held to help better explain the clinical experiences of NCAA sports medicine staffs that are not readily available in the public health literature. In addition, the NCAA currently is working both with the ASH and the Centers for Disease Control on a tool kit for the general population about sickle cell trait and its possible risks. 

As for other and perhaps unstated oppositions at last year’s Convention, one could have been simply a resistance to being told what to do. As a bedrock principle of Division III, many people cited “institutional autonomy” as a better route to manage the situation according to schools’ specific needs. It wasn’t that people didn’t agree with the need to protect student-athlete health and safety, but they were uncomfortable with a nationally mandated approach.

Others wondered why sickle cell was such a focus when other issues such as cardiac health appear more pressing. The competitive-safeguards committee explained that cardiac testing isn’t as far along as the mechanisms in place to determine sickle cell trait status.

“Sometimes there’s a resistance to being told what to do,” Washington and Lee’s Hathorn said. “I’m also one of those people who wonder whether the cardiac issues are more salient right now. However, the competitive-safeguards committee, which consists of medical professionals, has stated that confirming sickle cell trait status is an important issue that can be addressed more immediately than some of the other medical issues our students face.”

Martinez acknowledged the concern about autonomy. “One of the things I’ve come to appreciate after having served for a while in the governance structure is the diversity of our division, not just in their institutional mission and makeup, but also in location, resources and the manner in which they are able to approach and address issues,” he said.

But he believes the educational outreach has been effective.

“We’re in the education business, and that’s a big deal,” said Martinez, a former member of the competitive-safeguards committee. “We’ve approached this more from an educational perspective, and in the revised proposal we have ensured that there’s an educational piece for all student-athletes and not just those who might opt for the waiver. We see this first and foremost as being important to educate our student-athletes about sickle cell trait status confirmation.”

While it’s impossible to predict the outcome of the vote in January, it is safe to say that those doing the voting will have a more informed idea about the buttons they push.

Presidents Council chair Jim Schmotter of Western Connecticut State noted the consistent educational outreach to governance groups, conferences, coaches and athletic trainers for the last 10 months.

“With two months still to go before the Convention, we are confident that we’ll have a well-informed delegation voting on this matter in January,” he said.